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Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure

Educational Objective
To understand the effects of using Prone Positioning in Non-intubated Patients when treating COVID-19 patients
1 Credit CME

Patients with coronavirus disease 2019 (COVID-19) are at risk for acute respiratory distress syndrome.1 In intubated patients with severe acute respiratory distress syndrome, early and prolonged (at least 12 hours daily) prone positioning (PP) improves oxygenation and decreases mortality.2,3 Because intensive care units (ICUs) are overloaded with patients with COVID-19, awake PP may be useful to improve oxygenation and prevent ICU transfers.4 The objective of the study was to evaluate the feasibility, efficacy, and tolerance of PP in awake patients with COVID-19 hospitalized outside the ICU.

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Article Information

Corresponding Author: Xavier Elharrar, MD, Service des Maladies Respiratoires, Centre Hospitalier d’Aix-en-Provence, Avenue des Tamaris, 13100 Aix-en-Provence, France (xavierelharrar@hotmail.com).

Accepted for Publication: May 1, 2020.

Published Online: May 15, 2020. doi:10.1001/jama.2020.8255

Author Contributions: Drs Elharrar and Trigui had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Elharrar and Trigui served as co–first authors, each with equal contribution to the manuscript.

Concept and design: Elharrar, Trigui, Prud’homme.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Elharrar, Trigui, Dols, Prud’homme.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Dols.

Administrative, technical, or material support: Martinez.

Supervision: Papazian.

Conflict of Interest Disclosures: Dr Papazian reported receiving personal fees from Air Liquide and Merck Sharp & Dohme, grants from Sedana, and nonfinancial support from Medtronic, Lowenstein, and Hamilton outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank Alaïs Giraud, MS, Clinical Research Department, Aix-en-Provence Hospital, for her contribution in the protocol submission and generating the data for this study. We thank Laurence Maulin, MD, Laurent Lefebvre, MD, and Pascal Granier, MD, as co-investigators (Centre Hospitalier d’Aix-en-Provence, France). Michael Aubourg, MSc, and Pierre Castel, MiM, provided English editing service. None of these individuals received compensation for their contributions.

References
1.
Grasselli  G , Zangrillo  A , Zanella  A ,  et al; COVID-19 Lombardy ICU Network.  Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy.   JAMA. Published online April 6, 2020. doi:10.1001/jama.2020.5394 PubMedGoogle Scholar
2.
Munshi  L , Del Sorbo  L , Adhikari  NKJ ,  et al.  Prone position for acute respiratory distress syndrome. a systematic review and meta-analysis.   Ann Am Thorac Soc. 2017;14(supplement_4):S280-S288. doi:10.1513/AnnalsATS.201704-343OTPubMedGoogle ScholarCrossref
3.
Guérin  C , Reignier  J , Richard  J-C ,  et al; PROSEVA Study Group.  Prone positioning in severe acute respiratory distress syndrome.   N Engl J Med. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103 PubMedGoogle ScholarCrossref
4.
Sun  Q , Qiu  H , Huang  M , Yang  Y .  Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province.   Ann Intensive Care. 2020;10(1):33. doi:10.1186/s13613-020-00650-2 PubMedGoogle ScholarCrossref
5.
Scaravilli  V , Grasselli  G , Castagna  L ,  et al.  Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study.   J Crit Care. 2015;30(6):1390-1394. doi:10.1016/j.jcrc.2015.07.008 PubMedGoogle ScholarCrossref
6.
Ding  L , Wang  L , Ma  W , He  H .  Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study.   Crit Care. 2020;24(1):28. doi:10.1186/s13054-020-2738-5 PubMedGoogle ScholarCrossref
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